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SAN TOAQUIN LOCAL HEALTH DIPTRICT <br /> UNDER, ND STORAGE TANK PROGRAM - FARM TANK INFORMA. •, FORM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F .DRV/O % f ki - 1. 1 � . / lgviU pktctF- <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA CDD■ <br /> 1 <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET I a <br /> Y <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME LNVIRCNMENTAL H;,4 UH' <br /> PERMM'SERVICE <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 21P CODE <br /> R <br /> CHECE HERE tf this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION t ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH DHCD CODE <br /> E /rv� 7 s /%6c�d�S Cel � 5 ` ` `/a`' <br /> R CITY STA1E 211 CODE <br /> Ll CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate box <br /> T "ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site D to or ( 1,100 gal. capacity) <br /> E <br /> XX PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNucRBkGUND TANK 2NFORMAT20W (List Additional tank information on separate sheet if needed) <br /> T TANK SHE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K /U b0 C) n 1989 Removed 3/9/89 <br /> 1U 00U 6/(�S ( 1989 <br /> F0 -ve-se 1989 <br /> 0 Removed 3/9/89 <br /> / lPnCQ' 1989 Removed <br /> 3/25/89 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DATE <br /> President 3/27/89 <br /> OFFICE HE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE a ACTIVE UGT a EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> 2 <br /> EH 23 044 (12/88) <br />